Glaucoma is an incurable, insidious eye disease.
For most people, the disease is quiet. As fluid slowly accumulates inside the eye, intraocular pressure (IOP) increases, damaging the optic nerve that transmits images from the eye to the brain. Despite the danger, most glaucoma patients do not cause pain or discomfort, making it difficult to determine when the condition is getting worse. Even eye doctors find it difficult to identify IOP fluctuations, allowing the disease to progress or treatments to lose efficacy.
For this reason, glaucoma is often called the silent thief of sight.
Like early coal miners seeking to detect deadly gas levels, ophthalmologists have had just one approach to checking IOP levels—office exams. New studies are showing that IOP often fluctuates throughout the day, and these fluctuations can occur early in the morning or later at night, outside normal office hours. Specialists like WDzٰ, MD, at the John A. Moran Eye Center’s are changing that paradigm with technology and research that can provide better care.
“With new technology, we are, in the simplest terms, creating a better canary,” said Wirostko.
Enter iCare HOME
Wirostko can offer a variety of treatments to manage glaucoma, from eye drops to surgeries, but measuring IOP is a north star for managing a patient’s care. She and other specialists know that glaucoma is more complicated than they initially believed. Due to IOP fluctuations, the office visit only provides a snapshot of what is happening in a patient’s eye.
Research has shown that the highest pressure often occurs during early waking hours, outside regular office hours. To chart these changes, ophthalmologists must schedule their patients for a 24-hour lab stay, which can be costly and inconvenient.
“Our prospective studies, such as , have shown that IOP fluctuation is a risk factor that has been linked to disease progression, but it has never been easy to monitor outside of the office,” said Wirostko.
“There has been a need for monitoring eye pressure continuously, similar to continuous blood pressure or glucose readings.”
Wirostko has advocated for better technology, such as the , which the Food and Drug Administration approved in 2017 as a prescription device that patients can use at home to measure eye pressure. Wirostko also uses the device in her practice and has performed clinical research on its efficacy with colleagues at Moran and the Wilmer Eye Institute at Johns Hopkins 㽶Ƶ School of Medicine.
“[When patients take] IOP measurements at home, it gives me a more complete picture of what is happening inside the eye and how daily activities, exercise, and topical and systemic medications may be affecting that pressure,” said Wirostko.
Riding the Treatment Rollercoaster
Like many patients, John Sharkey was surprised by his glaucoma diagnosis. He sought the help of Wirostko mid-way through his glaucoma treatment journey.
By the time he retired from his law practice 25 years ago, Sharkey had already cycled through different glaucoma therapies, beginning with eye drops before progressing to laser eye surgery. Wirostko introduced him to the iCare HOME2, a compact device that provides rapid, easy-to-use, and precise eye pressure measurements from the comfort of one’s home.
“I liked having the feedback — not just absolute pressure — but how it changes,” said Sharkey. “My results showed quite a bit of variability during the day.”
, known as a tonometer, has built-in sensors that help the patient make subtle adjustments to match the contours of their face and align the device with their eye. Like many routine tests during an eye exam, the patient looks at a light in the device while pressure readings are captured.
“It wasn’t hard,” said Sharkey. “[The tonometer] is how I found out one of my surgeries had failed. I was able to get back on medication and schedule the next surgery.”
iCare HOME2 takes six measurements in rapid succession, eliminating the lowest and highest numbers and logging an average of the remaining readings. The data, which is displayed graphically and in a table, also captures metadata, such as the date and time when the measurement was taken. The data is downloaded wirelessly to a secure cloud server that the patient and doctor can access.
Like Sharkey, Justin Wilson was also surprised by his glaucoma diagnosis.
“Your biggest fear is the fear of the unknown,” he said. “With the tonometer, I can be proactive, not reactive, in my care. Daily monitoring allows me to be immediately aware of any IOP issues and not have to wait for bi-annual office visits — a true game changer.”
Wilson also began his therapy with eye drops, but after each new treatment failed to reign in his eye pressure, he began to turn to more invasive therapies. Wilson also sought treatment from Wirostko, where he felt the Moran Eye Center treated him as an individual, not another number walking through the door.
“Eyes are not cookie-cutter or one-size-fits-all business. ... At the Moran Eye Center, they look at you as an individual, and they treat your individual problem.”
The Burden of Glaucoma
According to the , glaucoma will continue to be a burden on the healthcare system.
Despite ongoing research, glaucoma continues to rob about 4.2 million Americans over the age of 40 of their vision.
, like iCare HOME2, have shown that patients with large daily pressure fluctuations tend to be younger, male, and have not previously undergone a surgical intervention.
Wirostko’s colleague, Rachel G. Simpson, MD, a glaucoma specialist at Moran, said the device has helped her find the most effective treatment for her patients. In one instance, she was able to identify a patient with worsening glaucoma who did not exhibit strong fluctuations in IOP. Simpson intervened with a different treatment to lower the eye pressure below the normal range to prevent damage to the optic nerve and bring the disease into check.
Making Patients Partners in Their Care
Currently, iCare HOME2 is not commonly covered by insurance, but the device is becoming a sought-after diagnostic tool, especially for patients in remote locations. Wirostko, a consultant to iCare, has co-founded , a licensed Durable Medical Equipment company that helps patients rent or buy the iCare HOME2 system. According to Wirostko, My Eyes has helped many patients recoup their out-of-pocket costs through insurance.
“Even if you are renting it for two weeks, you get a good idea of variability,” said Sharkey. “It is nice to know when the surgery is not working and can get back in to see the doctor to evaluate your situation sooner.”
To increase accessibility, clinicians are now calling for more extensive clinical trials to evaluate the data gathered by the device and improve guidance for clinical decision-making. According to Wirostko, home and remote tonometry devices could be the way of the future, similar to continuous glucose monitors for diabetes— improving access to care and removing barriers.
“There comes a point in glaucoma care at which point interventions have less bang for their buck in terms of preventing disease progression, and we need to adjust therapies,” said Wirostko.
“I have found this device helps me identify the ‘why’ and empowers the patient to understand their disease as well as adhere to therapies, making them a partner in their care.”